Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

Your ad here...

Contact us for rates.

Sponsored Sites

Sunday, May 16, 2010

I am an Emergency Physician and every day I go down the rabbit hole into the insane world of American Medicine. The waiting room is always full and despite the bogus statistics promulgated by ACEP to justify our existence, the majority of presenting complaints are nowhere close to being emergencies. In fact, most of what I see requires no organized medical intervention of any kind. Your toddler with a fever, for example, would do just as well with a little Wal Mart Ibuprofen as he does after a three-hour wait and a few hundred bucks of the taxpayer's money. And no, I'm not going to run lab tests and shoot a chest xray on a kid who is running around the room stuffing Cheetos into his mouth. Your rash? I can't even see it and if I could, so what? People get rashes. Same with your headache. People get headaches. We take a Tylenol. It's not meningitis. You're not bleeding in your skull. Your vitals are normal and the imperious way you hold up one finger to keep me from interrupting your phone conversation speaks volumes. I'm not giving you a shot and Motrin works for everybody despite what you tell me. It's a chemistry thing.

I am an Emergency Physician and this is not the Golden Age of Medicine lovingly described by the older doctors whose shoes I am not worthy to fill. You had your Virchow's Triad and your Grey Cullen sign but I am not so fortunate. People used to wait to go to the doctor and when you saw them they had a distinct constellation of symptoms around which you could wrap an eponym to demonstrate your genius. Today most of my patients present with a little bit of pain here or some dull ache there or some vague constipation a week ago and "I've been feeling some chills." I dare not ask the question-of-doom because the patient will get a faraway look and say, "You know, come to think of it I did have a little chest pain."

I am an Emergency Physician and everybody lies to me. There was a time when going to the Emergency Department was a big event in life. Even going to your own doctor was usually reserved for real but less urgent problems. Today everything is "ten-out-of-ten" on the pain scale. Or twelve. But you were asleep when I walked in...or you were polishing off a hamburger and fries. Can your pain really be that intense and more importantly, does it really need powerful narcotics? Are you really here for pelvic pain or do you really just want a pregnancy test or a picture of your seven week fetus to show the babydaddy and your momma told you what to say to the stupid doctor? Is this just a lame story to get a work note? Your next fix? Thank god most drug-seekers aren't towering intellectuals because they could, after an hour of Internet research, construct an airtight story complete with sham exam findings that would be hard for any doctor to defeat.

I am an Emergency Physician and I work in an Emergency Department that sits astride the major trade routes trafficking in the elderly and whose supporting hospital was strategically placed to command this trade and its rich plunder; bountiful cargoes of stable but chronic disease, vague complaints, and loneliness that fill our coffers with splendid treasures to rival the hordes of ancient kings. Or I dump hundreds of thousands of dollars into futile care. How I plunder the federal galleon like a modern-day freebooter, raking in the Medicare doubloons to extend the futile quasi-life of the living dead for whom death would be merciful!

I am Panda Bear. You may know me as a once prolific blogger who sort of faded away after he finished residency last June. I've been busy. Inexplicably I am working more hours than I did as a resident. I'm less stressed but the reality is that medical school and residency wiped me out financially and I have no choice. The scariest moment of my medical career was the day before I got my first real paycheck when I realized that my entire net worth was the half-gallon of gas in the tank of my ten-year-old car. Sure, I got a nice check the next day and began to staunch the financial hemorrhage but it's not pleasant to be 45 with no money, no savings, no investments, no credit, and a terrifying debt burden the bill for which had now come due. I tried not to think about it but if something had happened to me my family would have starved.

Naturally I'm divorced even though nine years ago my ex-wife and I would have laughed if you had said it could happen to us. Residency was just too much for my most excellent ex-wife who got tired of me being tired and of the residency program, the patients, and the hospital stealing the best parts of me leaving nothing but exhaustion and bitterness at home.

The usual lithany of complaints, without any constructive thought towards improvement. Even the sarcasm lacks originality and the remark about the Cheetos eating patient once was originally amusing before it became an over used cliche. What was your point? No, really, what was it?

Panda, Umm you DO know there supposed to pay you during residency??? OK, I know your Ex-Wife's gettin a big chunk of your earnings, just think of it as a really expensive Hooker you don't get to have sex with. And you've got noone to blame but yourself, God helps those who hire professionals to "Take Care" of there Ex-Wifes.Seriously, I haven't heard as much whining since we had my wife's pommeranian fixed.Anyways, if you wanta refinance that usurous student loan let me know,

Lots of people with huge loans due these days. Many of these people are unable to find employment. You have employment. You can see patient after easy (although irritating) patient and still get paid well. This is one good thing in life you have going. Is it that you want T R A U M A ? Panda, you know where to find it.

You see, it’s like you’ve spent so many years being all about YOU, that you’ve regressed. To accomplish what you have, it’s nearly impossible not to. You need to know people outside of your profession to get perspective. I think that you just might find that you’ve spent a little too much time worrying about self, and that others might find you rather ridiculous (as you might find yourself) once you crawl out of your small world and see some sunshine. Yes, you’ve achieved a lot, and have sacrificed dearly. But the world will just never give you the appreciation you crave. NEVER gonna happen. Divorce? Well, it happens to a lot of people. Wasn’t it clearly stated in not so fine print, that marriage can be contraindicated while in residency? At least you own up to some of the responsibility for home and work, all are active choices you made, and shit does happen. But now what? Don’t ruminate yourself into a depression that you will not be able to pull yourself out of. What we do is not the easy way through life. Set some limits to the damage you are doing to yourself.

this post is very interesting to me because i feel as if most of us here on this blog have written posts quite like it ever since this blogs inception (though probably never as clearly), and, more so, because i think there are some fundamentally unsettling and dangerous ideas contained in some of the comments.

first, and to anonymous1, i agree that this post is consistent with Panda's posts from his old blog and that it contains themes and statements he has made before. it, i think, is more rightly seen as a 'rant' or polemic that a whine, and, as such, i think the thing to ask is if PandaBear is portraying the state of Emergency Medicine as it really is generally, locally for him, or dishonestly. then we can answer the second criticism on anon1, that it is a rant without constructive solutions offered.

no amount of protestation will convince many folks that the ER is what Panda says it is... what we say it is... until they have to go there. now some folks who end up in the ER, folks that Panda and the rest of us would happily take care of, come away horrified by simply sitting in the waiting room for an hour. others hit the ER on a day when there is little or no wait, they get in and out, and they don't believe anything is amiss.

that's fine, it's just the way the odds shake out, but there is something extremely interesting about an anonymous commenter who, evidently, thinks PandaBear is a whiner, and yet follows him across the blogosphere to insult him anonymously in his new home. why bother anonymous? why?

as to the criticism that PandaBear criticizes, but offers no solutions, this is a feeble argument at best. a polemic or rant or criticism is not made invalid or untrue simply because it does not offer solutions. but offer solutions we have, as has PandaBear on his old blog, as we continue to do. and it is in these solutions that a sharp divide exists between most Americans.

quite simply those of us who write here would say something along these lines... American medicine is the best in the world, but is under assault and will not survive if something is not done.

no one is denied care, regardless of their ability to pay, but, EMTALA (unconstitutional on its face?) has been so liberally interpreted as to make it impossible to turn anyone away from the door for any reason whatsoever. now we have ambulances acting as taxis and ER visits for bruises. how to fix this? allow ER docs to say to those who receive care at others expense, "you do not have a medical emergency, please arrange to be seen by a primary care physician. you may either choose to pay X or you may leave. good day."

of course, those who use the ER for their primary care desires and to get stuff for free think this is unfair because... well, their arguments are not logical, they are emotional. those who get off on taking from one group and giving to another are also against this. it's really quite that simple.

the 'debate' over health care really comes down to an issue of individual rights and responsibilities. the fashion these days is that individual identity and responsibility is to be shunned and group identity and responsibility is to be embraced. has it ever worked? sure it has, jonestown, ussr, cambodia, the solar temple, north korea, and american academia. it has worked to spread misery and suffering and death (in the case of American academia i will leave out the 'death' but add 'syphilis').

jump on Panda for yelling 'fire' in a theater, but there is a fire. eventually the fire is too hot for even the most hearty folks to stand it, and that is when the real crisis in American medicine starts... when those like Panda look around and say, 'that's it, i'm done.'

unfortunately, this is already happening and, without exaggeration, many people will die because of it. historically, this may not even end up as a footnote, and such is life. younger.

frank,somehow you continue to make me laugh. i greatly admire the skill with which you navigate your profession and the humor you use in keeping your eyes averted from the train crash.

SCRN,some of what you say i believe to be wise, but it is in its wisdom that the true nature of the tragedy is evident. the part i like about what you say is the bit about ruminating into a depression. having done that myself i agree that it is a danger.

i must strongly disagree with the other idea, however, that simply being able to see 'patient after easy patient' should be enough. if i understand you you are equating a steady and handsome (by world standars) income with happiness. not true. i do not know Panda personally so can only say this, i would work for half of what i make now in the ER under two conditions...

1. i could say 'no' to patients without fear of losing my job2. i could spend at least half of my time taking care of medical emergencies (we know what they are and we know what they aren't)

the sea-change in medicine in the last 30 years has been to take this power away from medicine's experts and to load us with more liability, less pay, longer hours, and less respect.

karma is a bitch, and Americans may just awake one day and realize what a terrible mistake they have made, but i don't think they will. they will just die younger.

@911Doc: I'm anon1 -- not sure if you meant to specify me, but I'm certainly not complaining. I liked his past blog, I liked his SDN posts, and I "liked" (er, appreciated, but feel badly for what he's saying) this post. Not at all critical of anything.

Everybody knows this is not the way to practice medicine. How many times have I heard, “push it fast, or it won’t work on me”. We all get what is going on, and all experience it.

I am sensitive when I know one of you is sinking. I feel it. My point is that, when caught in the throws of self-destruction it is often wise to compare what you have to others on the most basic life needs level. We tend to stick with each other because we are the only ones who know what it is to be like us. That might be the worst thing we can do in reality. Venting is good but sometimes it’s healthy to step away and surround yourself with close non-medical friends who you would NEVER subject to ranting. Why? Because you know ranting can become selfish… I hope you can understand what I am getting at. Best to stop focusing on self so that you can keep your “self”.

The amount of pay to be happy was not my point. Simply having the ability to be employed at all in these hard times -- being thankful for something, anything, is an age old drug-free way to cope when things really suck. Not even funny how solid that is, it’s only good.

Got sent this link because I'm famous for being an attending upset with new docs like Panda. Guys who never should have got in the game and make everybody miserable just by showing up each day and bitching.

911 and oldfart can gripe all they like, emergency medicine has changed - for the worse.

Panda, did you not know what the job would be? Nobody applies to be a fireman thinking they'll only handle fires. No one becomes a cop thinking they will only handle bank robberies. Emergency medicine aint emergencies. Emergency aint for you.

45 is way late to start a new residency, but if you hate the job, hate the patients, hate the Emergency Department . . .

Get out. Get out now, for us and for you.

Three years more of residency and massive increase in your loan interest is a small price to pay for not hating life.

please do send along some of whatever you are smoking. of course the oxygen is a little thin up there, so it just may be hypoxia. white is black, cold is hot, and YOU FUCKING ROCK like the guy who writes 'movin meat'. i humbly aspire to have anosmia like you.

dear SCRN,

i kindly must take exception to your comment. it is heavy on kumbaya and short on logic. here's what i mean.

i do not deny that it is always a good idea to count our blessings, but if one follows this to it's extremes one could be the second most pitiful or pained human in the world and be admonished, by well-meaning folks, to count our blessings that we are not number one on the list.

you also have a bit of a hidden assumption in your comment that is just wrong, or, if it is right, then us arguing makes no sense and your opinion is mere accident as is mine.

your assumption is that Panda (and me and you and everyone)are where we are, and in the jobs we are in, because of happenstance. we are 'winners of life's lottery' as drippy dick gephardt used to say.

in fact, and obviously, i disagree. i don't know about you, but i thank God for the situation of my birth and upbringing, but chalk a good deal of who i am now up to hard work and determination. therefore, it is ESPECIALLY in times like these (when some of our fellow countrymen are nearly hungry, and nearly poor, and are not quite sure if they will have their cell phone next month) when our hard work and hard study pays the most dividends... we have a hard won skill, therefore in bad times we still have work. when this ceases to be the case then we will settle disagreements like this with knives, or clubs, or guns.

i am not saying that there are not situations where people are born into inescapable poverty or inescapable doom, but i am saying that most every time i meet one of these people here in the US, they are obese and continuing to make the same poor choices that they made (in this country of opportunity for all that people risk their very lives to enter across a hundred miles of desert) when they were sixteen and twenty-five and forty-six.

so, either you are right, and we are simply at a cosmic roulette wheel, or choices and personal initiative are the direct cause of our future. if the latter, then Panda, and I, are right to expect EVERYONE to admit and accept responsibility for themselves and their health and their bills etc... if the latter, then who better to listen to (when talking about problems with modern medicine in America) than physicians who still go to work to take excellent care of the pitiful mass that is the ER waiting room? if the latter then Panda just may be the alarm bell that people ignore at their peril.

47% = percentage of Americans who do not pay income tax (this number does not, of course, include 'undocumented' folks)

911, you are over-thinking... and are a stubborn little rat! Will you stop fighting me? I'd kick your ass if I could reach you. You don't get it at all. You are missing the forest for the trees! Can what I said be so way over your head? Quit giving stats and politics knee-jerk. This info you keep rolling out is common knowledge to even the lay public. What I suggest is not easy for a tough guy like you to wrap your brain around. But hey, I only told you because I thought you might be able to "get it" but instead you get pissed and hide behind your stats, choosing to find the most silly and simple-minded use for what I've said. I think you know that.

Don't complain when you break down and you have to pay some shrink for less. (Now, that was mean, I know).

already done that thanks. much better now. and i still have no idea what your point is so let me guess.

i think what you mean is that focusing on the obvious inequities and unfairness and misery will make us miserable. okay. i agree.

i think you also mean that we should, for our own happiness and sanity, focus on the positives and relish the good things in life. okay, agreed. how do you know this is not what we do outside of this little venue?

for that matter, how do any of you commentors here know what i (or panda or 'cat or lofty or oldfart or erdoc85) are like at the patient's bedside? do you assume we are angry like we are here? you would be wrong.

this blog is my vent. all of you are assuming things about us which are based on your imaginings of who is behind this curtain, and, you are as likely to be right in your assumptions as you are to guess the next flip of a coin, perhaps less, because we often say things that are out of favor in the conventional wisdom, so we must be beasts, right?

did it ever strike you that one of the reasons we do this as anonymously as possible is because talking like this openly could cost us our jobs? if you believe this, then you must agree that being a medblogger is risky, and, since i make enough to fill my gas tank occasionally from this blog i'm not doing it for the money. because i remain largely anonymous it ain't for the fame either. could it be that i care so deeply about medicine and taking care of patient's that watching a magical and wonderful thing being smashed forces me to speak up and to fight?

JFK got elected as a democrat saying 'ask not what your country can do for you....' obama got elected promising to take from some and give to more. i am not supposed to fight this? i am not supposed to point it out?

not pointing it out is exactly how we got here. sorry, if i go down it will be in defiance and it will not be quietly.

and dear scrn, i am now off to enjoy a glass of wine and a good movie, so please do something equally relaxing and pleasurable. we are big boys, boys fight, and then the storm passes.

i think i quoted this statistic already. my point (and, if i may, one of sPanda's points) is that 80% of visits to the ER are not emergencies and that THIS NEED NOT AND SHOULD NOT BE THE CASE.

i think, if you would simply read the post, that Panda asserts that it has only been this way for a short period of time.

my argument is that EMTALA, a sledgehammer used to kill a fly, has made the ER a miserable place for patients and nurses and docs because it has taken clinical judgement and the ability to say 'no' out of the hands of the very people who KNOW WHAT AN EMERGENCY IS. and all in the name of vote buying.

9-11, I agree, being an Emergency Physician sucks. People spit at you, lie to you, and its nothing like "Scrubs". OK it doesnt suck as much as hiding from the Nazis in a hidden room for 3 years and dying of Typhus in Bergen-Belsen, but its the same Ballpark.Thats why I'm restricting my practice to Vasectomies, Epidural Steroids, and Digital Stereo Manual Breast Palpations.

If it makes anything better, you should know that there are some patients who do see, really see, what happens and think incredibly highly of you for doing what you do every day.

My son had really bad ashtma as a baby, which thankfully he seems to be outgrowing a little (but let's pretend I didn't say that out loud because it makes me sort of nervous even though rationally I do know you can't really jinx something) and we frequently were in the ER with him. As I sat there with my baby barely breathing, and looked around I saw the "emergencies" people came in for. Really? Really your kid is sick? Then why is he able to walk around while laughing and stick his snotty fingers all over me and my son who can't even sit up because he is struggling just to breathe? And really? You are pissed that we got taken before you? Really? You think we should wait until after you get looked at? Because I'm thinking if we waited, my son would be dead but if you wait you might have a good burp and feel all better and just go home. (although I guess probably not on the just go home part...probably the burp would get added to the "symptom" list)

Just so you are aware, people like me really appreciate that people like you do what you do despite the people who make it kind of awful. I always went back with cookies for the nurses and doctors that were so wonderful to my son and hopefully someone will do that for you soon.

frank, really, did you have to make your point by citing bergen-belsen? then again, i hear it was more 'ritzy' than the other camps and that all folks had to worry about there were random executions, death by starvation, death by work, and diptheria (or was it typhus)?

I appreciate everyone's digust at the "system" as it is - I'm in healthcare & feel as though I'm a fast-food worker (pharmacist). Yes, I can be fired over telling someone no and get sh*t from you physicians as well.

So, I get it from both sides.

But, you ever wonder if part of your result was your age & if you really were meant to be in EM? I say that because I have a son a year behind you - he's in his final year of EM residency & 15 years younger. He's married, but no children yet.

The stresses of the field (altho I'm not sure there is an "easy" residency) in addition to your age & responsibilities you had when you traveled it had to take its toll. As a spouse, I know I'd be tired of being poor, having to be the sole provider & parent while you went & followed your dream....and became grumpier & grumpier as you went along.

So - as one poster alluded to - was this really a dream worth becoming reality - or should it have stayed a dream? The system didn't cause your divorce & current unhappiness at the state of your financial prospects - you did. Each choice you made along the way cemented the outcome.

What did you really want? What do you want now? Choices, choices, choices.....

Welcome back Panda to the goat rodeo that is emergency medicine (to quote somebody famous)

In deference to the anonymous lay-psych interpretations of PB's post, allow one more spin on the merry-go-round

I saw this post more as a biting indictment of society then the alleged panda-blues. He said, at least to me, that at great personal cost he daily goes down the "rabbit hole" where all is not what it is supposed to be.

The term "emergency" has been redefined as any symptom, real or imagined, for which the patient needs an answer NOW!! Plaintiffs...uh...I mean patients will lie to get high, embellish to get attention, deceive to force us to believe that their malady is the worst crisis in the emergency department ever. Forget about that GSW... I have been waiting an hour for my fibromyalgia flair and I want narcs now! We do not see the classic Grey Turner sign because the entitled have shown up long before their pancreatitis did. (OK, not all patients, but enough)

To suggest that panda is depressed (maybe he is or isn't, or the antidepressants wore off) or should "get out now" (I know I want to, and perhaps I should) misses the point entirely. Given what happens in a modern emergency department, we are all depressed at times. And were we to "get out now" then there would be nobody left. Our therapy is to vent. To each other, or if you have the wordcraft, to blogs, or if you don't, to a cat named Spanky. (although she is not much of a listener).

And now with the great oil slick called Health Care Reform about to tar up our shores, cut Panda a break. He is the messenger, not the news.

Many of you don't get it. There is no "getting out." What am I going to do? Go back to engineering for a sixth of what I'm making now? Likewise, saying that somehow I should have known how ridiculous medicine has become is idiotic. You don't really learn this until it's too late. My problem is that I am s rational, intelligent, hard-working guy in a system whose rules are created and mutated by bureaucrats and lawyers who have a vested interest in keeping things the way they are.

Suggestions to improve things? Meaningful legal reform and an end to the welfare state.

To put things in perspective, I got a patient complaint because I didn't order any lab work on a well-looking patient with the sniffles. The response from my administration? Maybe I should just order lab tests (and presumably imaging) just to keep the customers happy.

PB, strong and excellent post. I would much rather Panda Bear take care of me or my family member in the ER (remarkably we somehow manage to not use the ER like a vending machine) than the narcissistic Anon commenter whose ego was so beautifully documented in his own above commentary. Although I do think he has excellent advice. Yes, PB, get out of the ER. And I would encourage ALL ER DOCS TO GET OUT OF THE ER. Let's see how long JCAHO, HIPPA, and EMTALA will last if there are no longer any providers who will put up with pain scales. Take a page out of Atlas Shrugged and go on strike. It is inappropriate for patients to threaten ER staff and get away with it b/c the administration is afraid that the thug might give us (cringe!) a bad "customer" satisfaction score! And God forbid I don't give John Smith his oxycontin Rx for his ankle sprain! When did we become a nation of such wimps? God truly help us.

I am very old and have seen a lot. But what is happening now is past sad.

PB says "how do I get out?" Don't the rest of you get it? The question should be, WHY IS HE ASKING THE QUESTION??

Don't y'all get it??

Medicine has become so unpalatable that we will NOT ALLOW our children to apply to medical school, much less go to medical school. What don't YOU understand? We didn't go in to medicine to make a million bucks a year. We did not go in to medicine to fight with insurance companies to pay us for services rendered either..And that is where we find ourselves now.

Hey guess what? If you take your car to the mechanic and he fixes it when do expect to take your car home? Before you pay the dude? Really?

Hey, here's a quick test. Why don't you pricks go find an American born, studied in a US medical school, and trained in a US residency doctor to take yourself to or your kids?(Heaven forbid try to find a male!) If you can do that, you better latch on to that person now and do not let go. In 10 years they will will not exist..And if you think there is NO DIFFERENCE then you deserve what you get..

Have you considered joining an Urgent Care Center? It's heresy I know. But as a soon to be 3rd year medical student very interested in Emergency Medicine, I consider it my retirement plan. It's great to have one of my favorite authors back.

Dr. Pheidippides runs in vain. Greece is lost. The American Spartans, it seems, are anything but.

It's fairly terrible to hear some of these stories. Panda has no incentive to lie, little to exaggerate. I can only assume that he culls little sympathy because he's been busy grinding his heels on the world-view that keeps personal responsibility, common sense, and humility as far from the zeitgeist as is politically expedient/psychosocially soothing.

Dr. Bear, thank you for the narrative. Your writing has likely done much more good than will ever come to light. Keep it up. You Greeks seem to have a thing for competence in the face of overwhelming odds.

Relax, Panda, you have a diagnosis. I heard about compassion fatigue from a military officer today. Psychiatry is bunk. Neuroplasticity rules. Haters step off, we are approaching 100% morbidity in America. Is everyone equally miserable yet? I'm sorry for venting, I have compassion fatigue and am 100% service-connected.

Wow...its like you are talking from my soul. I wonder if you graduated from my residency (email me at serenitynowhospital@gmail.com). SCRN...your a dumb bitch. Get a life. We defy natural selection every day and we are tired of saving trolls

Its one of those "The Grass is Greener on the other side of the Fence" things...Like how my sister bitches about how hard her Air Traffic Controller job is, makin 150K/yr for basically playin video games 20 hrs/week, which is more like 10 when you account for lunch, smoke breaks etc etc.. Then I remind her how she was turnin tricks for $20/pop a few yrs ago and she won't bitch for a few days...

Panda, sorry to hear about your plight and your divorce. I'm running out of money here also as I finish up my psych NP program. Damn sure glad I went that route though, along with my shamanic training. I'm such a happy man!

Panda--welcome! Short bio--I used to be an attorney, now I'm a kindergarten teacher, and there have been plenty of shocks along the way re: what "teaching" entails these days (do they really expect me to cut their kids' fingernails?) Best advice, in all seriousness: Remarry well and invest emotionally in a hobby/sport/activity that you love. Takes the edge off. Best wishes!

Welcome to medicine, Panda I am also getting out of this shit hole. I have 15 years in this bitch and there is no reciprocity.

Fuck the clipboard patrols, I don't practice customer service driven medicine, the patient is not the ordering provider, House MD is a retard, yes I was on Trauma Life In The ER and did not even get any fucking residuals off of it.

Sadly, over my time I have seen the ER transform from a place to deal with urgencies and emergencies into the "safety net" of American Medicine, always patrolled by trial lawyers looking for anything they can turn into a payday.

In residency, they teach you science. You spend time in Journal Clubs and debating evidence based medicine. You learn indications for tests and studies, and WHEN you’re expected to pull the trigger on such things. Then you enter the world and find that no one gives a whit about such things. Most patients with a stubbed toe demand an X-ray. Parents of little kids who bonk their head on the coffee table believe Junior “must” have a CT.

Beyond taking excellent care of patients, our specialty has transformed into one of "meeting customer's expectations". The emphasis on our knowledge and background has taken a back seat to our "bedside manner".

Many in ACEP push us toward a public health mission which the pinheads at the CDC just love. Sure, pap smears in the ER…(over my dead body). ACEP is rapidly becoming our version of the AMA dominated by the panty-waste-touchy-feely in our specialty who don’t actually PRACTICE medicine.

Mathematicians have tried to turn much of clinical medicine into formulas and decision trees. These have been adopted by Government bureaucrats and nurses with clip boards who second-guess too many of our decisions (not based on clinical grounds, but based on checklists).

How well we adhere to these "checklists" is viewed by the Joint Commission as "quality" and soon will be used to reimburse us (or as we all know...used to decrease our reimbursement).

Coders & billers have co opted the patient's medical record and turned it into a billing document. (Last shift, I had the chart Nazi track me down for not completing the Review of Systems, Past Medical History, & Family History on a lady who just wanted a tetanus shot after she pricked her finger on some barbed wire).

In short, being a physician in the ER isn't about being a physician taking of patients with emergencies. There are many days where I don't see an "emergency".

I still enjoy taking care of patients. I just abhor the other BS that goes along with it. I still believe that the majority of patients are appreciative.

Still, all in all, I consider myself fortunate to be doing what I am doing.

I have read Panda's posts on and off over the past several years through random people linking his blogs. Someone just linked me to this site and now here I am again. I just wanted to say that I really appreciate your posts, as well as all the other doctors on this blog (okay so I just started reading this an hour ago, but so far, it's great!). I'm currently studying for step 1 and this has made for an interesting break. :)

Panda:You need to remember....this is a job. Yes an important job, but a job nonetheless. I am also your age and this is also my second career. At the end of the day (when not on call) I go home, spend time with those I love and what I love to do. I am sure you probably make more than I given you are a private ER doc, but I am also rather sure my quality of life is better than yours. In the end is it more important to make a bunch of dough or spend time with those you love? Maybe it is time to take a good long hard look at how you want to spend the next 20-25 years. Just a thought....Good luck.

There are hundreds of thousands of people who would jump for the chance to make $150+ an hour doing the job you describe. It's too easy for you? Boo hoo. Patients get angry? Boo hoo. My sister gets abused in retail for $8 an hour every single day of the week.

The real question is, would you take a pay cut to see only high acuity patients? Probably not. Yet you complain that the hospital wants to make money to pay your salary, in turn delivering you easier patients that make your job much simpler than patients with actual emergencies.

yet another brilliant post by an anonymi...we all just woke up one day in our current jobs... boy were we lucky to spin the wheel and hit on ER doctor. we have no right to complain. the things we complain about are purely self serving and have nothing to do with a crumbling system that is already making high quality medical care nearly impossible for people like you sister.

a) "I stubbed my toe an hour ago" (no mark on them and they are not limping )b)"I got shot at"c)"I felt dizzy headed last week"d)"I vomited yesterday and I need a work excuse"e)the patients who walk in, hop onto the stretcher then writhe with back pain wanting drugsf)the patients that we see over and over with STD's who REFUSE to go to the health dept and won't use condoms. The health dept charges $10.

These are actual cases. The last 3 are frequent, the last one is multiple times a day.

These people feel no responsibility to pay and don't care if the hospital goes bankrupt (which ours did, we're operating under Chapter 11 and have fired all of the people who stock our supplies. We’re working with a skeleton crew of nurses, housekeepers, and care providers).

These are the same patients who DEMAND that the doctor hurry and see them. They complain when they don't get what they WANT and their ER visit is over 2 hours.

I complain about these patients because they do not pay to keep the lights on, the scanners running, the staff working, and the rooms stocked with supplies (which frequently they steal), and yes, my salary too. I complain about them because they take my time away from seeing patients that really need my time and services.

We complain because all of our education is being turned into checklists by non-practicing "academics", some with health care degrees who justify their existence by expanding policies year after year. They only add to an already burdensome load of rules, regulations and paperwork which HINDERS us.

I resent politicians who don't understand the first thing about healthcare delivery in the "real world" who make laws and lay down regulations which are not practical while ignoring practicing physicians and instead find academicians and researchers to parade in front of the cameras.

I resent politicians who want to promise the ignorant public "pie in the sky" then blame the health care system when their impractical ideas do not work; then pass more laws and regulations which make the situation worse.

I resent the burdensome load of paperwork and the fact that it takes me longer to complete the paperwork than it does to see and care for the patient.

I abhor the "logic" that people FEEL as if it is reasonable and just to FORCE me to provide my knowledge and labor for free to people whose only goal in life is to take from society as much as they can. They sanction this behavior by a ridiculous notion that I have more, thus it is my DUTY to give to people who demand and do not give back. If I complain, they try to guilt me by saying that I went into medicine just for money. I complain because I am tired of people who loot my intellectual property and my labor because they feel as if they have a right to it merely because they exist.

There is a difference between freely giving something and being forced to give something because someone demands it. One makes you feel good. The other makes you feel resentful.

I am not talking about the truly needy. I am talking about the smokers with cell phones & expensive clothes who want Rx's for Tylenol and refuse to pay a dime for medical care or see a PCP or walk-in clinic for minor issues.

I am talking about the lady I saw this week who complained that the Gub'ment would only give her $800 a month to feed her 5 kids...and they went through 5 boxes of oatmeal a week. (When I asked why she didn't buy the cheap tub of generic quick oats, then add some sugar and brown sugar like I do, she scoffed that it takes too much time).

I would like for people who don't understand our jobs, to recognize our difficulties, and realize that government will never improve anything with rules & regulations.